The death of a 27-year-old man who killed himself in a hospital toilet after waiting 22 hours to be seen by the mental health team was “contributed to by neglect”, a coroner has ruled.
Jamie Pearson was admitted to Blackpool Victoria hospital’s A&E department after taking an overdose of high-strength painkillers on 17 August 2024.
An inquest heard that Pearson should have been seen within four hours by mental health specialists but was deemed low risk and was still waiting 22 hours later when he killed himself in a toilet.
His mother, Julie Knowles, previously told the Guardian her son was “badly failed and let down” by health professionals.
Julie Knowles, Jamie Pearson’s mother, said her son had been ‘largely ignored’ by hospital staff. Photograph: Christopher Thomond/The Guardian
Alan Wilson, the senior coroner for Blackpool and Fylde, concluded on Tuesday that Pearson’s death had been “contributed to by neglect”. He said the cumulative effect of the missed opportunities to provide mental health care “very comfortably” crossed the high threshold required for a finding of neglect.
The inquest heard that the hospital was struggling to manage patient levels at the time, with no medical bed available. This meant Pearson was left in a waiting area overnight and into the following day.
A communication breakdown meant that plans were not made for mental health specialists to see him as a priority, the coroner was told.
Knowles, who is now considering legal action against the NHS trust that runs the hospital, said her son had been “largely ignored” despite being “so vulnerable and suffering a breakdown”.
Pearson had told his mother in the waiting room that he still felt suicidal, so she went to inform a nurse and asked when he would be seen a mental health worker. “The nurse then walked over to Jamie with her hands on her hips and stated quite bluntly that he needed to be medically fit before he was referred to the mental health team,” she said.
“I’ll never forget Jamie’s face when that happened; he looked totally deflated. He was shot down and talked to appallingly and bluntly, almost like he was an inconvenience to them.
“I remain convinced that the attitude of that nurse set him back, as he was already feeling fragile, and I think her lack of empathy affected him.”
Amy Rossall, of Hudgell Solicitors, said the inquest had identified “a string of failings and missed opportunities” to prevent Pearson’s death.
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The inquest at Blackpool coroner’s court heard Pearson was classed as low risk despite his previous suicide attempt, his complaint in A&E of still feeling suicidal and his desperation to see a mental health worker.
Rossall said hourly observations of him were also not taken and recorded as they should have been. She said: “This is an exceptionally tragic case. Lessons may now have been learned as a result, but that is little consolation to Jamie’s mother, who believed at the time that he was in safe hands and in the best place given the fragility of his mental state.
“It was clear Jamie was at risk of serious harm having taken an overdose, and attempted to ligature. This inquest has highlighted a string of failings and missed opportunities to ensure Jamie was properly assessed and treated”.
Blackpool Teaching Hospitals, the NHS trust that runs Blackpool Victoria hospital, has been contacted for comment.
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, you can call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
